Pediatric Symptom Checklist (PSC) LF-35Subject Reference/ID: Cognitive Screening Test Date: April 1, 2014 17:27:52

Age: 21 Administrator: PSC Screening

Total Test Time: 1:10 (min:secs) Language: English (United States)

Administered using CNS Vital Signs Online Version 1.0

Completed by: good4 Fidgety, unable to sit still 2 - Often7 Acts as if driven by a motor 1 - Sometimes8 Daydreams too much 2 - Often9 Distracted easily 2 - Often14 Has trouble concentrating 1 - Sometimes Attention Problem Subscale 8

11 Feels sad, unhappy 1 - Sometimes13 Feels hopeless 1 - Sometimes19 Down on him or herself 2 - Often22 Worries a lot 2 - Often27 Seems to be having less fun 2 - Often Anxiety/Depression Subscale 8

16 Fights with other children 1 - Sometimes29 Does not listen to rules 2 - Often31 Does not understand other people's feelings 2 - Often32 Teases others 2 - Often33 Blames others for his or her troubles 2 - Often34 Takes things that do not belong to him or her 2 - Often35 Refuses to share 2 - Often Conduct Problem Subscale 131 Complains of aches or pains 2 - Often2 Spends more time alone 2 - Often3 Tires easily, little energy 1 - Sometimes5 Has trouble with teacher 2 - Often6 Less interested in school 2 - Often10 Is afraid of new situations 2 - Often12 Is irritable, angry 2 - Often15 Less interested in friends 1 - Sometimes17 Absent from school 2 - Often18 School grades dropping 2 - Often20 Visits doctor with doctor finding nothing wrong 2 - Often21 Has trouble sleeping 2 - Often23 Wants to be with you more than before 2 - Often24 Feels he or she is bad 2 - Often25 Takes unnecessary risks 2 - Often26 Gets hurt frequently 2 - Often28 Acts younger than children his or her age 2 - Often30 Does not show feelings 2 - Often PSC 35 Total Score 63

36. Does your child have any emotional or behavioral problems for whichshe/he needs help? Yes37. Are there any services that you would like your child to receive forthese problems? Yes38. If yes, what type of services? no one

Instructions for Scoring:The number that precedes each item only represents the sequence inwhich the item was asked. The standard parent completed PSC formconsists of 35-items that are rated as "never", "sometimes", or "often"present and scored 0, 1, and 2, respectively. Item scores are summed,with a possible range of scores from 0-70. This computerized version doesnot allow the participant to skip questions.

How to Interpret the PSC:A positive score on the PSC suggests the need for further evaluation by aqualified health (M.D., PsyD., R.N.) or mental health (Ph.D, LICSW)professional. The total score is recoded into a dichotomous variableindicating a possibility of AT RISK* or NOT at RISK of psychosocialimpairment.

PSC 35 Total Score:AT RISK* - Children with scores of 28 or higher usually have significantimpairments in overall psychosocial functioning.NOT at RISK - Children with scores of 27 or below usually do not havesignificant impairments in overall psychosocial functioning.

Attention Problem Subscale:AT RISK* - Children with scores of 7 or higher on this subscale usuallyhave significant impairments in attention.NOT at RISK - Children with scores of 6 or below on this subscale usuallydo not have significant impairments in attention.

Anxiety/Depression Subscale:AT RISK* - Children with scores of 5 or higher on this subscale usuallyhave significant impairments with anxiety and/or depression.NOT at RISK - Children with scores 4 or below on this subscale usually donot have significant problems with anxiety and/or depression.

Conduct Problem Subscale:AT RISK* - Children with scores of 7 or higher on this subscale usuallyhave significant problems with conduct.NOT at RISK - Children with scores 6 or below on this subscale usually donot have significant problems with conduct.

*Note: Scores in the AT RISK range usually warrant further evaluation butare not in themselves specific diagnoses.

Used with permission copyright 1999 M.S. Jellinek and J. M. Murphy,Massachusetts General Hospital (http://psc.partners.org)